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Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis

Ellen R Wald, MD
Section Editors
Morven S Edwards, MD
Anna H Messner, MD
Deputy Editor
Mary M Torchia, MD


Group A Streptococcus (GAS), also known as Streptococcus pyogenes, is the most common cause of bacterial pharyngitis in children and adolescents. The clinical features and diagnosis of GAS pharyngitis in children and adolescents will be discussed here. The treatment, prevention, and complications of GAS pharyngitis and the evaluation of acute pharyngitis in children and adults are discussed separately.

(See "Treatment and prevention of streptococcal pharyngitis".)

(See "Complications of streptococcal tonsillopharyngitis".)

(See "Evaluation of sore throat in children".)

(See "Evaluation of acute pharyngitis in adults".)

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Literature review current through: Nov 2017. | This topic last updated: Jun 07, 2017.
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  1. Pichichero ME. Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment. Ann Emerg Med 1995; 25:390.
  2. Tsevat J, Kotagal UR. Management of sore throats in children: a cost-effectiveness analysis. Arch Pediatr Adolesc Med 1999; 153:681.
  3. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55:e86.
  4. Kronman MP, Zhou C, Mangione-Smith R. Bacterial prevalence and antimicrobial prescribing trends for acute respiratory tract infections. Pediatrics 2014; 134:e956.
  5. Danchin MH, Rogers S, Kelpie L, et al. Burden of acute sore throat and group A streptococcal pharyngitis in school-aged children and their families in Australia. Pediatrics 2007; 120:950.
  6. Nussinovitch M, Finkelstein Y, Amir J, Varsano I. Group A beta-hemolytic streptococcal pharyngitis in preschool children aged 3 months to 5 years. Clin Pediatr (Phila) 1999; 38:357.
  7. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics 2010; 126:e557.
  8. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation 2009; 119:1541.
  9. Pfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A streptococcal pharyngitis. Pediatrics 2008; 121:229.
  10. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr 2012; 160:487.
  11. Breese BB. A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child 1977; 131:514.
  12. Wald ER, Green MD, Schwartz B, Barbadora K. A streptococcal score card revisited. Pediatr Emerg Care 1998; 14:109.
  13. Attia M, Zaoutis T, Eppes S, et al. Multivariate predictive models for group A beta-hemolytic streptococcal pharyngitis in children. Acad Emerg Med 1999; 6:8.
  14. Attia MW, Zaoutis T, Klein JD, Meier FA. Performance of a predictive model for streptococcal pharyngitis in children. Arch Pediatr Adolesc Med 2001; 155:687.
  15. Cohen JF, Cohen R, Levy C, et al. Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study. CMAJ 2015; 187:23.
  16. Roggen I, van Berlaer G, Gordts F, et al. Centor criteria in children in a paediatric emergency department: for what it is worth. BMJ Open 2013; 3.
  17. Woods WA, Carter CT, Schlager TA. Detection of group A streptococci in children under 3 years of age with pharyngitis. Pediatr Emerg Care 1999; 15:338.
  18. Powers GF, Boivert PL. Age as a factor in Streptococcosis. J Pediatr 1944; 25:481.
  19. Gunnarsson RK, Holm SE, Söderström M. The prevalence of beta-haemolytic streptococci in throat specimens from healthy children and adults. Implications for the clinical value of throat cultures. Scand J Prim Health Care 1997; 15:149.
  20. Marshall HS, Richmond P, Nissen M, et al. Group A Streptococcal Carriage and Seroepidemiology in Children up to 10 Years of Age in Australia. Pediatr Infect Dis J 2015; 34:831.
  21. American Academy of Pediatrics. Group A streptococcal infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.732.
  22. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998; 279:875.
  23. Lin MH, Fong WK, Chang PF, et al. Predictive value of clinical features in differentiating group A beta-hemolytic streptococcal pharyngitis in children. J Microbiol Immunol Infect 2003; 36:21.
  24. Shapiro DJ, Lindgren CE, Neuman MI, Fine AM. Viral Features and Testing for Streptococcal Pharyngitis. Pediatrics 2017; 139.
  25. Edmonson MB, Farwell KR. Relationship between the clinical likelihood of group a streptococcal pharyngitis and the sensitivity of a rapid antigen-detection test in a pediatric practice. Pediatrics 2005; 115:280.
  26. McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004; 291:1587.
  27. Dingle TC, Abbott AN, Fang FC. Reflexive culture in adolescents and adults with group A streptococcal pharyngitis. Clin Infect Dis 2014; 59:643.
  28. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis 2013; 57:e22.
  29. Carroll K, Reimer L. Microbiology and laboratory diagnosis of upper respiratory tract infections. Clin Infect Dis 1996; 23:442.
  30. Kurtz B, Kurtz M, Roe M, Todd J. Importance of inoculum size and sampling effect in rapid antigen detection for diagnosis of Streptococcus pyogenes pharyngitis. J Clin Microbiol 2000; 38:279.
  31. Cohen JF, Chalumeau M, Levy C, et al. Spectrum and inoculum size effect of a rapid antigen detection test for group A streptococcus in children with pharyngitis. PLoS One 2012; 7:e39085.
  32. Bisno AL. Acute pharyngitis. N Engl J Med 2001; 344:205.
  33. Gerber MA. Comparison of throat cultures and rapid strep tests for diagnosis of streptococcal pharyngitis. Pediatr Infect Dis J 1989; 8:820.
  34. Kellogg JA. Suitability of throat culture procedures for detection of group A streptococci and as reference standards for evaluation of streptococcal antigen detection kits. J Clin Microbiol 1990; 28:165.
  35. Armengol CE, Schlager TA, Hendley JO. Sensitivity of a rapid antigen detection test for group A streptococci in a private pediatric office setting: answering the Red Book's request for validation. Pediatrics 2004; 113:924.
  36. Dagnelie CF, Bartelink ML, van der Graaf Y, et al. Towards a better diagnosis of throat infections (with group A beta-haemolytic streptococcus) in general practice. Br J Gen Pract 1998; 48:959.
  37. Roddey OF Jr, Clegg HW, Martin ES, et al. Comparison of an optical immunoassay technique with two culture methods for the detection of group A streptococci in a pediatric office. J Pediatr 1995; 126:931.
  38. Gerber MA, Tanz RR, Kabat W, et al. Optical immunoassay test for group A beta-hemolytic streptococcal pharyngitis. An office-based, multicenter investigation. JAMA 1997; 277:899.
  39. Daly JA, Korgenski EK, Munson AC, Llausas-Magana E. Optical immunoassay for streptococcal pharyngitis: evaluation of accuracy with routine and mucoid strains associated with acute rheumatic fever outbreak in the intermountain area of the United States. J Clin Microbiol 1994; 32:531.
  40. Pichichero ME, Disney FA, Talpey WB, et al. Adverse and beneficial effects of immediate treatment of Group A beta-hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J 1987; 6:635.
  41. el-Daher NT, Hijazi SS, Rawashdeh NM, et al. Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V. Pediatr Infect Dis J 1991; 10:126.
  42. Gieseker KE, Mackenzie T, Roe MH, Todd JK. Comparison of two rapid Streptococcus pyogenes diagnostic tests with a rigorous culture standard. Pediatr Infect Dis J 2002; 21:922.
  43. Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev 2004; 17:571.
  44. Tanz RR, Gerber MA, Kabat W, et al. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics 2009; 123:437.
  45. Lean WL, Arnup S, Danchin M, Steer AC. Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis. Pediatrics 2014; 134:771.
  46. Stewart EH, Davis B, Clemans-Taylor BL, et al. Rapid antigen group A streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis. PLoS One 2014; 9:e111727.
  47. Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with pharyngitis. Cochrane Database Syst Rev 2016; 7:CD010502.
  48. Pritt BS, Patel R, Kirn TJ, Thomson RB Jr. Point-Counterpoint: A Nucleic Acid Amplification Test for Streptococcus pyogenes Should Replace Antigen Detection and Culture for Detection of Bacterial Pharyngitis. J Clin Microbiol 2016; 54:2413.
  49. Uhl JR, Adamson SC, Vetter EA, et al. Comparison of LightCycler PCR, rapid antigen immunoassay, and culture for detection of group A streptococci from throat swabs. J Clin Microbiol 2003; 41:242.
  50. Uhl JR, Patel R. Fifteen-Minute Detection of Streptococcus pyogenes in Throat Swabs by Use of a Commercially Available Point-of-Care PCR Assay. J Clin Microbiol 2016; 54:815.
  51. Cohen DM, Russo ME, Jaggi P, et al. Multicenter Clinical Evaluation of the Novel Alere i Strep A Isothermal Nucleic Acid Amplification Test. J Clin Microbiol 2015; 53:2258.
  52. Rush MC, Simon MW. Occurrence of Epstein-Barr virus illness in children diagnosed with group A streptococcal pharyngitis. Clin Pediatr (Phila) 2003; 42:417.
  53. Hofkosh D, Wald ER, Chiponis DM. Prevalence of non-group-A beta-hemolytic streptococci in childhood pharyngitis. South Med J 1988; 81:329.
  54. Gerber MA, Randolph MF, Martin NJ, et al. Community-wide outbreak of group G streptococcal pharyngitis. Pediatrics 1991; 87:598.
  55. Turner JC, Hayden FG, Lobo MC, et al. Epidemiologic evidence for Lancefield group C beta-hemolytic streptococci as a cause of exudative pharyngitis in college students. J Clin Microbiol 1997; 35:1.
  56. Zaoutis T, Attia M, Gross R, Klein J. The role of group C and group G streptococci in acute pharyngitis in children. Clin Microbiol Infect 2004; 10:37.
  57. Mackenzie A, Fuite LA, Chan FT, et al. Incidence and pathogenicity of Arcanobacterium haemolyticum during a 2-year study in Ottawa. Clin Infect Dis 1995; 21:177.
  58. Carlson P, Renkonen OV, Kontiainen S. Arcanobacterium haemolyticum and streptococcal pharyngitis. Scand J Infect Dis 1994; 26:283.
  59. Carlson P, Kontianinen S, Renkonen OV, et al. Arcanobacterium haemolyticum and streptococcal pharyngitis in army conscripts. Scand J Infect Dis 1995; 27:17.
  60. Karpathios T, Drakonaki S, Zervoudaki A, et al. Arcanobacterium haemolyticum in children with presumed streptococcal pharyngotonsillitis or scarlet fever. J Pediatr 1992; 121:735.
  61. American Academy of Pediatrics. Arcanobacterium haemolyticum infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.246.
  62. Foy HM. Infections caused by Mycoplasma pneumoniae and possible carrier state in different populations of patients. Clin Infect Dis 1993; 17 Suppl 1:S37.
  63. Esposito S, Blasi F, Bosis S, et al. Aetiology of acute pharyngitis: the role of atypical bacteria. J Med Microbiol 2004; 53:645.
  64. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am 2005; 52:729.
  65. Putto A. Febrile exudative tonsillitis: viral or streptococcal? Pediatrics 1987; 80:6.
  66. Ebell MH, Call M, Shinholser J, Gardner J. Does This Patient Have Infectious Mononucleosis?: The Rational Clinical Examination Systematic Review. JAMA 2016; 315:1502.
  67. Del Mar C, Pincus D. Incidence patterns of respiratory illness in Queensland estimated from sentinel general practice. Aust Fam Physician 1995; 24:625.
  68. Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:1003.
  69. Sharland M, Hodgson J, Davies EG, et al. Enteroviral pharyngitis diagnosed by reverse transcriptase-polymerase chain reaction. Arch Dis Child 1996; 74:462.